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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 055I sch Ite 't r Traces - 953"77 <br /> JOB ADDRESS FLL Q �1 a too CITY/ZIP m <br /> ^� 378 1 D <br /> CROSS STREETT, <br /> tftne t; IA Q APN Log 1 In a 9 PARCEL SIZEA LASE APPLICATION# o <br /> OWNER NAME ( {Q.,(��-l�.O ��/j� (� t�501 PHON�Ep �+ <br /> OWNER ADDRESS/p WIf'J'�� /1 . CITY/STATE/ZJP �YG5l-Q 40 �ic�TZi <br /> CONTRACTOR P t�f I Ql PI PHONE )A <br /> CONTRACTOR ADDRESS 2,pnl Arch— ;LT`f- Raa-L S-;he IQQ CITY/STATE/ZIP SbOAlm, CNI552Q6 <br /> SUBCONTRACTOR/CONSULTANT PHONE �flq.9�� .X755 <br /> SU13CONTRACT/ORICONSULTANT ADDRESS CITY/STATE/ZIP�G a At CSA I 55631- <br /> LICENSE <br /> 5631- <br /> LICENSE y!C-57 I C-61 ❑ D-09 -1 Other NUMBER :120404 EXPIRATION DATE Oy.3 o.2 07 _ <br /> BILLING PARTY: L.OWNER CONTRACTOR F' SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)ri Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE r I Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring if Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well L Replacement Well _-Well Alteration/Modification Other <br /> MonitoringWell(s) #ofwells 0Soil Borings) #of borings �Geotechnical ofborings <br /> Out-Of-Service Well C!Out-Of-Service Well Renewal Cross-Connection Repair <br /> -New Pump a Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method J Mud Rotary ❑Air Rotary j Auger C!Cable Tool L Push Point ❑ Other <br /> Proposed Well Depth S_30 It Excavation in diameter ❑Open Bottom []Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched u Steel ❑Plastic C Stainless Steel I- Other <br /> Grout Seal Depth ft 4 Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix 7 gal water <br /> - Bentonite(20%solids) E Other <br /> Grout Placement Method 4 Pumped Free Fall - Other =Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller -Pump Contractor - Other <br /> Concrete Pedestal-Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible�i Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM OUR ADVANCNOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ,p <br /> SIGNED R TITLE 6 0' DATE <br /> NT <br /> Al <br /> VE® <br /> 2019 <br /> 5 N COUNTY <br /> E NTAL <br /> H T TMENT <br /> PSA TMENT U E O LY ��ii��' . <br /> Application Accepted By Date Area Employee ID#-I�C7�� <br /> Grout Inspection By Date _ SPECIAL ell Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted at S rvice Re ue t Invoice# Well ID# <br /> 4 <br /> EHD43-06 6111r2019 WELL/PUMP PERMIT <br />